Evidence review: Adults with complex needs (with a particular focus on street begging and street sleeping) Adults with complex needs (with a particular focus on street begging and street sleeping) About Public Health England Public Health England exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. We do this through world-leading science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health, and are a distinct delivery organisation with operational autonomy to advise and support government, local authorities and the NHS in a professionally independent manner. Public Health England Wellington House 133-155 Waterloo Road London SE1 8UG Tel: 020 7654 8000 www.gov.uk/phe Twitter: @PHE_uk Facebook: www.facebook.com/PublicHealthEngland Prepared by: Emma Seria-Walker. 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Published: January 2018 PHE publications PHE supports the UN gateway number: 2017683 Sustainable Development Goals 2 Adults with complex needs (with a particular focus on street begging and street sleeping) Contents About Public Health England 2 Acknowledgements 5 Executive summary 6 1.0 Introduction 8 2.0 Context 8 3.0 Literature review methodology and scope 12 4.0 Definitions 13 Homeless 13 Hidden homeless 13 Multiple Exclusion Homelessness (MEH) 14 Rough sleepers 14 Street homeless 14 Begging 14 5.0 National profile of people who street beg and/or street sleep 15 Street begging 15 Rough sleepers 17 Homelessness more generally 23 Gender, age, ethnicity and learning difficulties 25 Geographic spread 27 Length of time spent on the streets and/or homeless 27 The overlap between street begging and street sleeping 28 6.0 What factors may be driving increases in homelessness? 30 7.0 Why do people street beg and/or street sleep? 32 8.0 The impact of street begging and/or street sleeping 40 The impact on individuals 40 Impact of homelessness on health 40 Impact on children and families 42 Impact on communities 42 9.0 Interventions – what works to prevent/ reduce street begging and street sleeping? 43 Early intervention in the context of homelessness 43 Integrated working and system wide approaches 44 Interventionist approaches Vs non-interventionist approaches 44 Promising interventions 45 Inclusion health 56 Models of homelessness provision 60 Street begging evidence 60 10.0 Impact of enforcement on street begging/street sleeping 62 3 Adults with complex needs (with a particular focus on street begging and street sleeping) 11.0 Financial costs of homelessness – what is the return on investment? 65 12.0 Conclusion 68 Recommendations 69 Appendix A: 70 Literature search – scope and results 70 Appendix B: 72 Trends in Rough Sleeping by Local Authority in the South East, 2010-2016 72 Appendix C: 77 Toolkits, guides and strategies that may be useful 77 Westminster Begging Strategy 77 Westminster Rough Sleeping Strategy 77 Prevention Opportunities Mapping and Planning Toolkit (PrOMPT) 77 Psychologically informed services for homeless people – Good Practice Guide 77 Meeting the psychological and emotional needs of homeless people. Mental Health Good Practice Guide 77 What it’s worth? Guidance on using financial savings analysis in the homeless sector 77 The impact on health of homelessness: A guide for local authorities 77 No excuses: under the youth accommodation pathway section 77 4 Adults with complex needs (with a particular focus on street begging and street sleeping) Acknowledgements Thank you very much to all those who provided advice, evidence, support and guidance throughout the development of this piece of work. In particular, Barbara Norrey from PHE Library Services for undertaking the initial literature search. Charlotte Matthews, Lisa Wills, Sandra Jerrim, Colin McAllister, Liz Slater, Jason Horsley, Felicity Ridgway, Mark Pirnie, Briony Tatum, Amy McCullough, Alan Knoble, Katy Bartolomeo, Jackie Hall, Cassandra Powers and Martin Buckmaster from Portsmouth and Southampton City Councils for your help in scoping and steering this work. The Safer Portsmouth Partnership for providing us with access to the work you are doing on those with complex needs. Dr Nick Maguire from Southampton University for providing your time, knowledge, expertise and research on this topic. 5 Adults with complex needs (with a particular focus on street begging and street sleeping) Executive summary Public Health England South East Centre was asked by Portsmouth and Southampton City Councils to provide an independent review of the literature around homelessness. With particular reference to those who are street homeless and those who street beg to support efforts to prevent and reduce homelessness and the adverse outcomes associated with this. The purpose of this document is, therefore, to provide an overview of the national picture in relation to homelessness and provide insights into the current evidence base to support action in preventing and reducing homelessness, particularly with those who are street sleeping and street begging. Homelessness in the UK is increasing and projections indicate that it set to continue to rise over the coming years, with significant numbers affected by the lack of availability and affordability of housing; changes to the benefits system; and a range of risk factors, which have been identified that mean that individuals have an increased likelihood of becoming homeless. Sections 2, 5, 6 and 7 explore the data, risk factors and reasons why people street beg, street sleep and/or experience homelessness and indicate that it is a highly complex mix of issues that combine, stemming from early childhood experiences through to the development of substance misuse and mental health problems. This, coupled with the significant social exclusion faced by these adults with complex needs, serves to make the provision of interventions and services to reduce and prevent homelessness incredibly difficult. Section 9 explores promising interventions from the literature that may support efforts to prevent and reduce homelessness. Some of the key interventions include: No Second Night Out Housing First Psychologically Informed Environments Personalised Services MEAM There was little primary research looking at interventions specifically to prevent or reduce street begging or street sleeping. Much of the literature relating to this is found in grey literature, policy or strategy papers, or informal news pieces. However, there are some key themes that have emerged, including: early intervention in the context of homelessness 6 Adults with complex needs (with a particular focus on street begging and street sleeping) integrated working interventionist approaches Vs non-interventionist approaches In addition, there has been a recent review of the evidence in relation to interventions for inclusion health, which highlight a number of areas where there is good evidence to support intervention, including: pharmacological interventions psychosocial interventions case management disease prevention housing and social determinants other interventions interventions tailored to women interventions tailored to young people What is clear is that no one single intervention on its own will reduce or prevent homelessness. A system wide, integrated approach is needed to ensure that there a range of linked services available to meet the needs of those with highly complex needs. A home is one of the key things required to support this group. Evidence suggests that simply having appropriate long-term accommodation can have a significant impact on those with complex needs, who are often the most socially isolated and excluded people within our communities. Sections 8, 10 and 11 explore some of the impacts associated with homelessness and particularly street begging and street sleeping, where evidence exists and highlights some of the potential savings that could be made through tackling this complex issue. There are a lack of return on investment tools to provide a robust judgement on the extent of those savings, but there is likely to be substantial gains to health and social services as well as benefits to the criminal justice system of addressing this issue. This review highlights some of the gaps in data, research and evidence that exist and recommends that: local authorities consider the findings of this review and how they may be able to utilise it in the context of their local situations (some toolkits, guides and strategies that may be useful can be found in Appendix C) PHE considers the research/evidence/data gaps in this area and how we may be able to overcome some of these and support the development of the evidence base for this highly complex and vulnerable group 7 Adults with complex needs (with a particular focus on street begging and street sleeping) 1.0 Introduction Public Health England South East Centre was asked by Portsmouth and Southampton City Councils to provide an independent review of the literature around homelessness. With particular reference to those who are street homeless